Essential to any individual's journey from mental illness to
recovery are moments when they (or those they know) realize that
something is wrong and they need help, that getting treatment can lead
to understanding and hope, and that recovery is possible when
strengths-based adaptation and ongoing effort are partnered with proper
treatment.

But many Americans who face mental health issues never get to that
first moment, realizing that they need help, and of those who do, many
find that treatment isn't available or fall away from treatment
before hope can take hold. Among the former group are those with
anosognosia, a condition that impairs their ability to recognize that
they have a mental illness.

The November 8 sentencing of Jared Lee Loughner, the
24-year-Arizonan diagnosed with schizophrenia after his arrest for the
Tucson shootings that killed six and seriously injured 12, reminds us
that for the few whose mental illnesses manifest in violent behavior,
only moments may separate the paths that lead to treatment, or to
tragedy.

What might have been?

Could the life of Jared Lee Loughner have gone in another direction
if he had received psychiatric treatment, including medications?
Possibly, yes. But the case of James Holmes, the young man accused in
the July movie-theater shootings in Aurora, Colorado, demonstrates that
accessing care is not sufficient to prevent violence and tragedy either.
Holmes had seen a University of Colorado psychiatrist, but did not
return--and was not sought out--after withdrawing from the university in
the middle of June, just five weeks before the shootings.

According to Paul Appelbaum, M.D., past president of the American
Psychiatric Association (APA) and chair of the APA's Committee on
Judicial Action, when violent behavior occurs as a manifestation of a
mental disorder, treatment "is likely to diminish the risk of
future violence." (He stresses that most acts of violence are
committed by people who are not mentally ill.)

Where there is a connection, however, treatment can help to prevent
violence by helping the patient understand that paranoia, for example,
is not justified, that the world is not "out to get" them.
"Someone with a paranoid delusional system who seeks revenge or
preemption in violent behavior is carrying out instrumental
violence," says Appelbaum, who is the Elizabeth K. Dollard
professor of psychiatry and law at Columbia University. "'They
think they have a goal, but it's a delusional one, protecting
themselves from imaginary, malevolent forces."

Aggression, even when planned in advance, can be a response to
being psychotic, agrees William Glazer, M.D., president of Glazer
Medical Solutions, based in Florida. "If you believe your food is
being poisoned, or that you are being monitored by the FBI, you are
going to get very scared," Glazer says. "At some point you may
get so out of touch that you will be violent and aggressive," he
adds, noting that if a patient's paranoia could be treated with
antipsychotic medication and a trusting therapeutic relationship, then
"the aggression would be treated as well."

But establishing an effective therapeutic bond takes time.
"Relationship" is the key to earning a person's trust,
convincing them to enter therapy, and motivating them to take medication
when it is necessary, says Lori Ashcraft, Ph.D., executive director of
the Recovery Opportunity Center at Recovery Innovations, in Phoenix,
Arizona. "They know if you are on their side, if you believe in
them," she says.

But such interventions aren't open to those who refuse
treatment or those who don't realize their own mental illness. What
then?

Involuntary commitment and treatment

Some form of involuntary commitment or treatment laws exist in
every state, with New York's Kendra's Law (New York) and
Laura's Law (Calif.) among the notable examples. Typically, these
laws allow for an individual to be court-ordered either to an
institution for a brief period or to an assisted outpatient treatment
(AOT) program for a longer period, or both. But laws set a high bar for
any intrusion on personal freedom: petitioners must prove that the
individual is gravely disabled or represents a significant or imminent
danger to self or others.

The height of the bar against involuntary treatment must be seen in
light of the civil rights struggles of the 1950s and '60s, and the
values of the recovery movement, which stresses the importance of
personal choices and strengths as critical elements in the recovery
process. But some worry privately that the pendulum has swung too far,
making it very very difficult to compel treatment or medication even
when the need appears obvious.

Convincing the patient

Persuading the patient to take medication, oral or injectable, is
often part of good treatment. But, as noted, informed consent requires
discussion of a potential litany of side effects, which may trigger
patient concern. "But fear that the patient will say no to the
medication is not a reason to deceive or to withhold information -
whether they're mentally ill, or paranoid, or not," says
Appelbaum. He believes that honesty--even about unpleasant side
effects--is most likely to win a patient's trust.

Mental Health America (MHA) recognizes that involuntary treatment
may be necessary, on an inpatient basis for crisis purposes. But MHA
does not support involuntary outpatient treatment. Almost everyone,
including people with serious mental illnesses, "are capable of
making their own decisions about whether to seek treatment and support
and what treatment and support they should receive," MHA says.

Though MHA agrees that psychotropic medications are effective, they
maintain that the known risks of these meds entitle consumers to refuse
them. "For this reason and because of its commitment to the
autonomy and dignity of persons with mental health conditions, MHA
strongly agrees with the judgment of the United States Supreme Court
that all persons, even persons lawfully convicted and serving a sentence
of imprisonment, have a right to refuse medication and that medication
may not be imposed involuntarily unless rigorous standards and
procedures are met," says MHA, citing the 1990 case Washington v.
Harper, 494 U.S.210.

Meds can reduce violence risk ...

How antipsychotic medications reduce the risk of violence in people
with schizophrenia living in the community has long been a question for
clinicians. Jeffrey Swanson, Ph.D., and colleagues found that
antipsychotics did not reduce the risk of violence in patients whose
childhood history of antisocial behavior suggests that their. violent
behavior was a result of that, and not of their psychosis--the reduction
was from 16 percent to 9 percent in the retained sample
("Comparison of antipsychotic medication effects on reducing
violence in people with schizophrenia," published in the British
Journal of Psychiatry in 2008). The report is part of the GATE (Clinical
Antipsychotic Trials of Intervention Effectiveness) study sponsored by
the National Institute of Mental Health, which found that the atypicals
are no more effective than the older--and much less
expensive--medications.

Being abused as a child is a definite risk factor for later
violence, whether the person is psychotic or not, says Swanson,
professor of psychiatry and behavioral sciences at Duke University
School of Medicine. But that doesn't mean that someone who has been
abused can't be helped after the fact, he says. "It may be
that because of the abuse they take a more hostile attitude to the
world." If they also have schizophrenia, the medication would help
prevent delusions that could compound violence related to that
hostility.

But supportive services are essential, too

Being on medication doesn't mean that patients with mental
illnesses will be cured, or that they won't be violent, says Marvin
S. Swartz, M.D., professor of psychiatry and behavioral sciences at Duke
University School of Medicine. "When deinstitutionalization
started, we thought all they needed to do was to take the
medications," he says. Now we recognize that even with optimal
medication, there are aspects of schizophrenia, for example, that
probably don't get addressed by medication - the self-care
deficits, the lack of awareness of illness, the cognitive
deficits."

Ashcraft asserts that supportive relationships, partnerships,
really--are at the heart of recovery. But programs like Ashcraft's
are not reimbursed by Medicaid, which only pays for medications in many
states. And in a time of budget cuts, states are cutting back on
enhanced services like Assertive Community Treatment (ACT) teams and
recovery-oriented programs.

The cost of the latest medications means that payers--whether state
programs or MBHOs, are squeezing money out of psychosocial treatment,
says Swartz. "As a result, it's going into the pharmacy
formulary, and now we're spending a huge amount on the
formulary," he said. "We seem to be facing a situation where
patients have a branded medication like Risperdal Consta and no
psychosocial treatment," he said. "Maybe we should consider
using a generic like Prolixin D with intensive psychosocial treatment -
this cost tradeoff might make sense." The problem occurs, he said,
because the federally mandated basic Medicaid plan pays for the
medication and simple doctor visits. The services that have become the
hallmark of good schizophrenia treatment - ACT teams and case managers -
are optional enhanced benefits and subject to budget cuts.

Most professionals would agree that if a choice has to be made
between the enhanced services--ACT teams, for example--and medications,
that the medications should come first, says Glazer. But let's not
kid ourselves that medications alone will take care of the problem.
Unless we can provide supportive services for these kinds of patients,
we're going to have more violence, more hospitalizations, and more
transfers to prisons which are now becoming the home for the mentally
ill."

RELATED ARTICLE: A role for medications

For those who enter treatment, medications are not indicated as
"treatment" for violent behavior, which in itself is not a
mental illness. But for people with schizophrenia or other serious
mental illnesses who have a history of violent behavior, and for whom
there is "some residual impairment that never gets back to
normal," maintenance antipsychotic medications are indicated, says
Appelbaum.

Antipsychotic medications can be administered in three ways:

* Oral, by consumption of a pill or liquid

* Intramuscular injection, which is often used in emergency
situations, and,

* Depot injection, which deposits a long-acting formulation of the
medication.

In general, depot formulations are for patients who are
"nonadherent"--those who refuse, are unwilling, or are unable
to maintain a regular dose of oral medications. For some, depot
injections (i.e., monthly) may be more convenient and easier to
remember. In addition, the appointment for the injection may provide an
ideal time for a caseworker to follow up on an individual's
progress.

Mention of antipsychotic medications raises the issue of side
effects, which can be significant. There are two broad categories of
antipsychotics: "first generation" medications such as
haloperidol and perphenazine, and the newer class known as
"atypicals," such as risperidone.

The atypical antipsychotics

aripiprazole (Abilify)

clozapine (Clozaril)

olanzapine (Zyprexa) *

palipericione (Invega)

quefiapine (Seroquel)

risperidone (Risperdal) *

ziprasidone (Geodon)

First-generation antipsychotics

fluphenazine (Prolixin) *

haloperidol (Haldol) *

perphenazine (Trilofon)

chlorpromazine (Thorazine)

trifluoroperazine (Stelazine)

* Depot (long-term) injectable formulations are available for these
drugs.